Soy protein infant formulae and follow-on formulae: a commentary by the ESPGHAN Committee on Nutrition

World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines update - XVI - Nutritional management of cow's milk allergy

Cow's milk allergy (CMA) is one of the most common presentations of food allergy in early childhood. Management of CMA involves individualized avoidance of cow's milk and other mammalian milk and foods containing these. Optimal elimination of cow's milk avoidance includes: label reading; information about safe and nutritious substitute foods; appropriate choice of infant formula or a plant-based food; establishing tolerance to baked milk and monitoring nutritional intake and growth. Substitute formulas are divided into soy formula (not hydrolyzed), milk-based extensively hydrolyzed formulas, rice based extensive, and partially hydrolyzed formulas and amino acid-based formulas. The use of other mammalian milks is not recommended for the management of cow's milk allergy due to a high level of cross-reactivity and nutritional concerns. For toddlers who are eating well, children, and adults, a suitable plant-based beverage may be a suitable alternative to a specialized formula, following careful nutritional considerations. Families need to be instructed on finding suitable nutritious foods and how to prepare suitable meals at home. Individuals with CMA also need to know how to identify and treat acute severe reactions.

Infant formulas for the treatment of functional gastrointestinal disorders: A position paper of the ESPGHAN Nutrition Committee

Functional gastrointestinal disorders (FGID), such as infant regurgitation, infant colic, and functional constipation, are common and typically physiological phenomena during the early months of an infant's life and account for frequent consultations with pediatricians. Various infant formulas are marketed for their management and are frequently given by parents to infants before a medical consultation. However, the evidence supporting their effectiveness is limited and some have altered nutritional compositions when compared to standard formulas. Thus, these products should only be used under medical supervision and upon medical advice. Marketing and over-the-counter sales do not ensure proper medical guidance and supervision. The aim of this position paper is to review the current evidence regarding the safety and efficacy of formulas specifically formulated for addressing regurgitation, colic, and constipation, recognized as FGID. The objective is to provide guidance for clinical management based on the highest quality of available evidence. A wide search using Pubmed, MEDLINE, EMBASE and Cochrane Database of Systematic Reviews was performed including the MESH terms infant formula, colic, constipation, regurgitation, reflux, palmitate, lactase, lactose, magnesium, hydrolyzed protein, prebiotics or probiotics. 752 papers were identified and screened. Finally, 72 papers were included in the paper. In the absence of evidence, recommendations reflect the authors' combined expert opinion. Final consensus was obtained by multiple e-mail exchange and meetings of the Nutrition Committee. (1) For breastfed infants experiencing FGID such as regurgitation, colic, or constipation, transitioning from breastfeeding to commercial formulas is not recommended. (2) In general, whether an infant is breastfed or formula-fed, it's crucial to reassure parents that FGIDs are normal and typically do not necessitate treatment or change to a special formula. (3) Thickened formulas, often termed anti-reflux formulas, may be considered in specific cases of regurgitation. (4) The usage of specialized formulas for infants with colic is not advised due to a lack of clinical evidence. (5) In the case of constipation in infants, the use of formulas enriched with high β-palmitate and increased magnesium content may be considered to soften the stool. Generally, there is limited evidence supporting the use of specialized formulas for FGID. Breastfeeding should never be discontinued in favor of formula feeding.

Diagnosis and management of food allergy-induced constipation in young children-An EAACI position paper

The recognition of constipation as a possible non-Immunoglobulin E (IgE)-mediated allergic condition is challenging because functional constipation (unrelated to food allergies) is a common health problem with a reported worldwide prevalence rate of up to 32.2% in children. However, many studies in children report challenge proven cow's milk allergy and constipation as a primary symptom and have found that between 28% and 78% of children improve on a cow's milk elimination diet. Due to the paucity of data and a focus on IgE-mediated allergy, not all food allergy guidelines list constipation as a symptom of food allergy. Yet, it is included in all cow's milk allergy guidelines available in English language. The Exploring Non-IgE-Mediated Allergy (ENIGMA) Task Force (TF) of the European Academy for Allergy and Clinical Immunology (EAACI) considers in this paper constipation in the context of failure of standard treatment and discuss the role of food allergens as culprit in constipation in children. This position paper used the Delphi approach in reaching consensus on both diagnosis and management, as currently published data are insufficient to support a systematic review.

Cow's Milk Protein Allergy

Cow's milk allergy refers to an immunological reaction to milk protein. It is one of the commonest food protein allergies with an estimated prevalence of 0.5% to 3% at 1 y of life. The disease may be IgE or non-IgE mediated or mixed with a wide range of symptoms often involving multiple organ systems. Gastrointestinal manifestations are common in non-IgE disease and may consist of enteropathy, proctocolitis, colic, reflux-like symptoms, constipation, enterocolitis syndrome and eosinophilic esophagitis. The gold standard for diagnosis remains a double-blind placebo-controlled oral challenge. Specific IgE and skin prick tests may predict severe and persistent disease, and aid in deciding on reintroduction or oral immunotherapy; however, they do not contribute to a definitive diagnosis as they indicate only sensitization. In practice, an elimination diet followed by open challenge under medical supervision is often used for diagnosis except when symptoms are severe such as anaphylaxis. Management consists of the elimination of the allergen with resolution of symptoms between 1-4 wk later depending on the type of allergy. Extensively hydrolyzed and Amino acid formulas are used to substitute milk in infants. Soy-based formulas are often utilized in resource-limited settings. Tolerance to the protein develops over time and periodic reintroduction should be attempted every six months after the initial one year of elimination diet. Oral immunotherapy is a newer treatment technique for IgE-mediated disease. There is no firm evidence on prevention apart from recommending breast feeding in early life along with initiating complementary feeding between 4-6 mo age.

World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guideline update - XII - Recommendations on milk formula supplements with and without probiotics for infants and toddlers with CMA

Background

Cow's milk allergy (CMA) is the most common food allergy in infants. The replacement with specialized formulas is an established clinical approach to ensure adequate growth and minimize the risk of severe allergic reactions when breastfeeding is not possible. Still, given the availability of multiple options, such as extensively hydrolyzed cow's milk protein formula (eHF-CM), amino acid formula (AAF), hydrolyzed rice formula (HRF) and soy formulas (SF), there is some uncertainty as to the most suitable choice with respect to health outcomes. Furthermore, the addition of probiotics to a formula has been proposed as a potential approach to maximize benefit.

Objective

These evidence-based guidelines from the World Allergy Organization (WAO) intend to support patients, clinicians, and others in decisions about the use of milk specialized formulas, with and without probiotics, for individuals with CMA.

Methods

WAO formed a multidisciplinary guideline panel balanced to include the views of all stakeholders and to minimize potential biases from competing interests. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to review by stakeholders.

Results

After reviewing the summarized evidence and thoroughly discussing the different management options, the WAO guideline panel suggests: a) using an extensively hydrolyzed (cow's milk) formula or a hydrolyzed rice formula as the first option for managing infants with immunoglobulin E (IgE) and non-IgE-mediated CMA who are not being breastfed. An amino-acid formula or a soy formula could be regarded as second and third options respectively; b) using either a formula without a probiotic or a casein-based extensively hydrolyzed formula containing Lacticaseibacillus rhamnosus GG (LGG) for infants with either IgE or non-IgE-mediated CMA.The issued recommendations are labeled as "conditional" following the GRADE approach due to the very low certainty about the health effects based on the available evidence.

Conclusions

If breastfeeding is not available, clinicians, patients, and their family members might want to discuss all the potential desirable and undesirable consequences of each formula in infants with CMA, integrating them with the patients' and caregivers' values and preferences, local availability, and cost, before deciding on a treatment option. We also suggest what research is needed to determine with greater certainty which formulas are likely to be the most beneficial, cost-effective, and equitable.

The Remaining Challenge to Diagnose and Manage Cow's Milk Allergy: An Opinion Paper to Daily Clinical Practice

Guidelines and recommendations for the diagnosis and management of cow's milk allergy (CMA) in childhood are based on scientific review of the available evidence. While this approach is the most rigorous, guidelines may not fully address all scenarios encountered by clinicians. Many symptoms of CMA overlap with other common childhood illnesses and are subjectively reported by the caregivers of the infant, as is the interpretation of the dietary interventions. Additionally, many healthcare professionals and caregivers do not follow the recommendations to perform an oral food challenge or reintroduction of cow's milk after a diagnostic elimination diet because (1) the infant is doing well and (2) the carer's fear of symptoms relapsing with this procedure. As a result, CMA in infants may be either under-diagnosed leading to reduced quality of life for families or over-diagnosed, resulting in unnecessary long-term elimination diets and increasing the risk for nutritional deficiencies. This paper discusses some of these controversial topics, focusing on misdiagnosis and mismanagement in clinical practice. The lack of objective diagnostic criteria can hamper the diagnosis and management of CMA in daily practice.

Plant-Based Milk Alternatives in Child Nutrition

Plant-based milk alternatives can be distinguished in two main categories, differing in production processes and regulation: plant-based formulas and plant-based drinks. They are now a widely accepted class of products on the international market. The various plant-based milk alternatives differ in nutritional characteristics due to their origin and manufacturing; more importantly, whereas formulas from plant and cow origin can be used interchangeably, plant-based drinks are nutritionally different from cow's milk and can be consumed by children subsequently to the use of formula. Several scientific organizations have expressed differing opinions on the use of these products in the diets of children. In the face of unanimous conclusions regarding the use of these products during the first year of life, in subsequent ages there were conflicting opinions regarding the timing, quantities, and type of product to be used. From the viewpoint of the child's overall diet and health, it could be suggested that these foods be considered not as simple substitutes for cow's milk, but as part of a varied diet, within individual advice of use. We suggest accepting the presence of these products in a baby's diet (omnivores included), planning their use correctly in the context of a balanced diet, according to the specific product and the needs of the individual.

The Protein Composition and In Vitro Digestive Characteristics of Animal- versus Plant-Based Infant Nutritional Products

The protein composition and digestive characteristics of four commercially available infant formulae (IF) manufactured using bovine (B-IF), caprine (C-IF), soy (S-IF), and rice (R-IF) as a protein source were examined in this study. Plant-based formulae had significantly higher crude protein and non-protein nitrogen (NPN) concentrations. Static in vitro gastrointestinal digestion of these formulae, and subsequent analysis of their digestates, revealed significantly higher proteolysis of B-IF at the end of gastrointestinal digestion compared to the other formulae, as indicated by the significantly higher concentration of free amine groups. Furthermore, differences in structure formation during the gastric phase of digestion were observed, with formation of a more continuous, firmer coagulum by C-IF, while R-IF demonstrated no curd formation likely due to the extensive hydrolysis of these proteins during manufacture. Differences in digestive characteristics between formulae manufactured from these different protein sources may influence the bio-accessibility and bioavailability of nutrients, warranting additional study.

Budget Impact of Early Introduction of Amino Acid Formula in Managing Infants with Cow Milk Protein Allergy: Arabian Gulf Countries' Experience

Objective

This study estimates the budgetary impact of the introduction of amino-acid formula (AAF) as first-line management in the elimination diet of infants with suspected cow milk protein allergy (CMPA) in the Kingdom of Saudi Arabia (KSA), Kuwait, and the United Arab Emirates (UAE) from a health-care payer's perspective.

Methods

A global decision tree model was adapted to compare estimated costs in current practice (extensively hydrolyzed formula [eHF] or soy formula [SF] with the proposed approach of early introduction of AAF as first-line treatment of CMPA in non-breast-fed infants). Model inputs were derived from explorative literature reviews and medical experts' opinions. All costs were reported in local currency, ie, Saudi Riyal (SAR) for KSA, Kuwaiti Dinar (KWD) for Kuwait, and United Arab Emirates Dirham (AED) for the UAE.

Results

Cost savings with the early introduction of AAF were 10% (SAR 15102542) in KSA, 10% (KWD 306565) in Kuwait, 17% (AED 1842018) in the UAE government sector and 13% (AED 4232932) in the UAE private sector. The highest cost reduction was observed in the cost of soy formula (SF), with a 58% reduction both in KSA (SAR 4204540) and UAE public sector (AED 110331). A significant cost reduction in medication costs in Kuwait (37%; KWD 5630) and medical examination costs in the UAE private sector (50%; AED 1508918) was observed.

Conclusion

Results indicated that the introduction of AAF as the first line in the management of CMPA is a cost-saving strategy for the Gulf Cooperation Council (GCC) countries-KSA, Kuwait, and UAE- from a health-care payer's perspective.

Soy-Based Infant Formula Feeding and Uterine Fibroid Development in a Prospective Ultrasound Study of Black/African-American Women

BACKGROUND

Uterine fibroids are highly prevalent, benign tumors. They are the leading indication for hysterectomy, and Black women are disproportionally burdened. Soy-based infant formula contains phytoestrogens, and exposure during sensitive developmental windows may adversely affect the developing uterus; early phytoestrogen treatment in rodent studies led to detrimental uterine effects, including increased fibroid risk in Eker rats. Limited epidemiological studies also have suggested increased fibroid development with soy formula infant feeding.

OBJECTIVE

The goal of this study was to examine the association between soy formula feeding in infancy and fibroid development in adulthood.

METHODS

We evaluated this association among 1,610 Black/African-American women age 23-35 y in the Study of Environment, Lifestyle & Fibroids (SELF). Soy formula feeding data was gathered directly from the participants' mothers (89%). A standardized ultrasound examination was conducted during 4 clinic visits over 5 y to detect fibroids ≥0.5cm in diameter. We used Cox proportional hazards regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between soy formula feeding and incident fibroids adjusted for early-life and adult factors. Fibroid growth was calculated as change in log-volume for fibroids matched at successive visits.

RESULTS

Of 1,121 fibroid-free participants at baseline, 150 (13%) were ever fed soy formula as infants, and 269 (24%) developed incident fibroids. We did not observe an association between ever being fed soy formula and incident fibroid risk (HR=1.08; 95% CI: 0.75, 1.54). However, participants fed soy formula within 2 months of birth and for >6 months (n=53) had an elevated risk of fibroid incidence in comparison with those never fed soy formula (HR=1.56; 95% CI: 0.92, 2.65). Fibroid growth rates did not differ.

DISCUSSION

Adding support to limited human data, this prospective fibroid study found that soy-based formula feeding during infancy was associated with a suggestive increase in risk of ultrasound-identified incident fibroids in adulthood. https://doi.org/10.1289/EHP11089.

Nutritional Management of Children with Food Allergies

Purpose of the Review

The purpose of the review is to review the evidence for the nutritional management of paediatric food allergy and provide a practical approach for healthcare professionals working in this area.

Recent Findings

Dietary elimination remains the mainstay for management of food allergies in children. However, the elimination of food allergens increases the risk for growth faltering, micronutrient deficiencies and feeding difficulties. Breastmilk remains the ideal source of nutrition for infants, but when not available, the vast majority will tolerate an extensively hydrolysed formula, and rice hydrolysate has also been suggested as a suitable alternative. Only in severe cases, including anaphylaxis, eosinophilic oesophagitis and growth faltering, is an amino acid formula indicated. The early introduction of peanut and egg and avoiding the delay in the introduction of other allergens, when not already allergic, has been highlighted by recent studies.

Summary

Whilst the elimination of allergens increases the risk of developing poor growth, micronutrient deficiencies and feeding difficulties, optimal, early dietary input, including advice on active introduction of allergens and alternative feeds, ideally from a registered dietitian/nutritionist, may be prevent and improve outcomes.

Diagnosis and management of food allergy-associated gastroesophageal reflux disease in young children-EAACI position paper

Gastro-oesophageal reflux (GOR) and food allergy (FA) are common conditions, especially during the first 12 months of life. When GOR leads to troublesome symptoms, that affect the daily functioning of the infant and family, it is referred to as GOR disease (GORD). The role of food allergens as a cause of GORD remains controversial. This European Academy of Allergy and Clinical Immunology (EAACI) position paper aims to review the evidence for FA-associated GORD in young children and translate this into clinical practice that guides healthcare professionals through the diagnosis of suspected FA-associated GORD and medical and dietary management. The task force (TF) on non-IgE mediated allergy consists of EAACI experts in paediatric gastroenterology, allergy, dietetics and psychology from Europe, United Kingdom, United States, Turkey and Brazil. Six clinical questions were formulated, amended and approved by the TF to guide this publication. A systematic literature search using PubMed, Cochrane and EMBASE databases (until June 2021) using predefined inclusion criteria based on the 6 questions was used. The TF also gained access to the database from the European Society of Paediatric Gastroenterology and Hepatology working group, who published guidelines on GORD and ensured that all publications used within that position paper were included. For each of the 6 questions, practice points were formulated, followed by a modified Delphi method consisting of anonymous web-based voting that was repeated with modified practice points where required, until at least 80% consensus for each practice point was achieved. This TF position paper shares the process, the discussion and consensus on all practice points on FA-associated GORD.

Pathogenesis, diagnosis, dietary management, and prevention of gastrointestinal disorders in the paediatric population

Nutrition has a central role in child growth with long-term effects, and nutrition management in gastrointestinal disorders has great importance for child health and disease outcomes. Breast milk is the first choice for infant nutrition. When it is not available, special milk formulas are adopted in specific conditions, as a medical treatment. Moving from the strong guidelines, recommendations and the new possibilities of special diet treatment, this review will analyse the current diet treatment in different gastrointestinal disorders, including food allergy, cystic fibrosis, inflammatory bowel diseases, short-bowel syndrome, gastroesophageal reflux, and eosinophilic esophagitis. The review also aimed at understanding the role of diet and its effects on these diseases. The growth monitoring can prevent malnutrition and improve disease outcomes, particularly in children, and an appropriate dietary management targeted to specific disorders is the best therapeutic choice alone or in combination with pharmacological therapy.

Managing food allergy: GA2LEN guideline 2022

Food allergy affects approximately 2-4% of children and adults. This guideline provides recommendations for managing food allergy from the Global Allergy and Asthma European Network (GA2LEN). A multidisciplinary international Task Force developed the guideline using the Appraisal of Guidelines for Research and Evaluation (AGREE) II framework and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. We reviewed the latest available evidence as of April 2021 (161 studies) and created recommendations by balancing benefits, harms, feasibility, and patient and clinician experiences. We suggest that people diagnosed with food allergy avoid triggering allergens (low certainty evidence). We suggest that infants with cow's milk allergy who need a breastmilk alternative use either hypoallergenic extensively hydrolyzed cow's milk formula or an amino acid-based formula (moderate certainty). For selected children with peanut allergy, we recommend oral immunotherapy (high certainty), though epicutaneous immunotherapy might be considered depending on individual preferences and availability (moderate certainty). We suggest considering oral immunotherapy for children with persistent severe hen's egg or cow's milk allergy (moderate certainty). There are significant gaps in evidence about safety and effectiveness of the various strategies. Research is needed to determine the best approaches to education, how to predict the risk of severe reactions, whether immunotherapy is cost-effective and whether biological therapies are effective alone or combined with allergen immunotherapy.

Formulation, pilot-scale preparation, physicochemical characterization and digestibility of a lentil protein-based model infant formula powder

BACKGROUND

Infant formula is a human milk substitute for consumption during the first months of life. The protein component of such products is generally of dairy origin. Alternative sources of protein, such as those of plant origin, are of interest due to dairy allergies, intolerances, and ethical and environmental considerations. Lentils have high levels of protein (20-30%) with a good amino acid profile and functional properties. In this study, a model lentil protein-based formula (LF), in powder format, was produced and compared to two commercial plant-based infant formulae (i.e., soy; SF and rice; RF) in terms of physicochemical properties and digestibility.

RESULTS

The macronutrient composition was similar between all the samples; however, RF and SF had larger volume-weighted mean particle diameters (D[4,3] of 121-134 μm) than LF (31.9 μm), which was confirmed using scanning electron and confocal laser microscopy. The larger particle sizes of the commercial powders were attributed to their agglomeration during the drying process. Regarding functional properties, the LF showed higher D[4,3] values (17.8 μm) after 18 h reconstitution in water, compared with the SF and RF (5.82 and 4.55 μm, respectively), which could be partially attributed to hydrophobic protein-protein interactions. Regarding viscosity at 95 °C and physical stability, LF was more stable than RF. The digestibility analysis showed LF to have similar values (P < 0.05) to the standard SF.

CONCLUSION

These results demonstrated that, from the nutritional and physicochemical perspectives, lentil proteins represent a good alternative to other sources of plant proteins (e.g., soy and rice) in infant nutritional products. © 2021 The Authors. Journal of The Science of Food and Agriculture published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Hydrolyzed Rice Formula: An Appropriate Choice for the Treatment of Cow's Milk Allergy

Cow's milk allergy (CMA) is a common condition in the pediatric population. CMA can induce a diverse range of symptoms of variable intensity. It occurs mainly in the first year of life, and if the child is not breastfed, hypoallergenic formula is the dietary treatment. Extensively hydrolyzed cow's milk formulas (eHF) with documented hypo-allergenicity can be recommended as the first choice, while amino acid-based formulas (AAF) are recommended for patients with more severe symptoms. Hydrolyzed rice-based formulas (HRFs) are a suitable alternative for infants with CMA that cannot tolerate or do not like eHF and in infants with severe forms of CMA. In the present paper, we reviewed the nutritional composition of HRFs as well as studies regarding their efficacy and tolerance in children, and we provided an updated overview of the recent evidence on the use of HRFs in CMA. The available studies provide evidence that HRFs exhibit excellent efficacy and tolerance and seem to be adequate in providing normal growth in healthy children as well as in children with CMA.

Pediatric Aspects of Nutrition Interventions for Disorders of Gut-Brain Interaction

Dietary factors may play an important role in the generation of symptoms in children with disorders of gut-brain interaction (DGBIs). Although dietary modification may provide successful treatment, there is a relative paucity of controlled trials that have shown the effectiveness of dietary interventions. This study is a narrative review that explores the existing literature on food and pediatric DGBIs. The following have been shown to be beneficial: (i) in infants with colic, removing cow's milk from the infant's diet or from the maternal diet in those who are breastfed; (ii) in infants with regurgitation, adding thickeners to the formula or removing cow's milk protein from the infant's diet or the maternal diet in those who are breastfed; and (iii) in children with pain-predominant DGBIs, using soluble fiber supplementation or a low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet. In children with functional constipation, there is no evidence that adding fiber is beneficial. Given that most dietary interventions include restriction of different foods in children, a thoughtful approach and close follow-up are needed.

Alternatives to Cow’s Milk-Based Infant Formulas in the Prevention and Management of Cow’s Milk Allergy

Cow’s milk-based infant formulas are the most common substitute to mother’s milk in infancy when breastfeeding is impossible or insufficient, as cow’s milk is a globally available source of mammalian proteins with high nutritional value. However, cow’s milk allergy (CMA) is the most prevalent type of food allergy among infants, affecting up to 3.8% of small children. Hypoallergenic infant formulas based on hydrolysed cow’s milk proteins are commercially available for the management of CMA. Yet, there is a growing demand for more options for infant feeding, both in general but especially for the prevention and management of CMA. Milk from other mammalian sources than the cow, such as goat, sheep, camel, donkey, and horse, has received some attention in the last decade due to the different protein composition profile and protein amino acid sequences, resulting in a potentially low cross-reactivity with cow’s milk proteins. Recently, proteins from plant sources, such as potato, lentil, chickpeas, quinoa, in addition to soy and rice, have gained increased interest due to their climate friendly and vegan status as well as potential lower allergenicity. In this review, we provide an overview of current and potential future infant formulas and their relevance in CMA prevention and management.

The Glycemic Response to Infant Formulas: A Randomized Clinical Trial

Background: Commercial infant formulas attempt to imitate human milk’s unique composition. However, lactose-free and milk protein-free formulas are often chosen due to medical reasons or personal preferences. The aim of this study was to determine the glycemic and insulinemic indices of a variety of infant formulas. Methods: We conducted a three-arm, randomized, double-blind, crossover study. Participants were 25–40-year-old healthy adults. Three commercial infant formulas (cow’s milk protein-based [“standard”], soy protein-based, and lactose-free) were randomly given to each participant. Glycemic and insulinemic responses were determined and compared between the three formulas. Results: Twenty subjects were enrolled (11 females/9 males, mean age 32.8 ± 2.9 years). No significant difference was found in the glycemic index between the three formulas (21.5, 29.1, and 21.5 for the standard, soy protein-based, and lactose-free formulas, respectively, p = 0.21). However, maximal glucose levels were significantly higher for the soy protein-based formula compared to both the standard and lactose-free formulas (111.5 compared to 101.8 and 105.8 mg/dL, respectively, p = 0.001). Conclusion: Cow’s milk protein-based, soy protein-based, and lactose-free formulas have a similar glycemic index. However, soy protein-based formula produced a significantly higher increase in postprandial glucose levels. The implication and biological significance of these results have yet to be determined.

Developmental exposure to phytoestrogens found in soy: New findings and clinical implications

Exposure to naturally derived estrogen receptor activators, such as the phytoestrogen genistein, can occur at physiologically relevant concentrations in the human diet. Soy-based infant formulas are of particular concern because infants consuming these products have serum genistein levels almost 20 times greater than those seen in vegetarian adults. Comparable exposures in animal studies have adverse physiologic effects. The timing of exposure is particularly concerning because infants undergo a steroid hormone-sensitive period termed "minipuberty" during which estrogenic chemical exposure may alter normal reproductive tissue patterning and function. The delay between genistein exposure and reproductive outcomes poses a unique challenge to collecting epidemiological data. In 2010, the U.S. National Toxicology Program monograph on the safety of the use of soy formula stated that the use of soy-based infant formula posed minimal concern and emphasized a lack of data from human subjects. Since then, several new human and animal studies have advanced our epidemiological and mechanistic understanding of the risks and benefits of phytoestrogen exposure. Here we aim to identify clinically relevant findings regarding phytoestrogen exposure and female reproductive outcomes from the past 10 years, with a focus on the phytoestrogen genistein, and explore the implications of these findings for soy infant formula recommendations. Research presented in this review will inform clinical practice and dietary recommendations for infants based on evidence from both clinical epidemiology and basic research advances in endocrinology and developmental biology from mechanistic in vitro and animal studies.

Case report: Goiter and overt hypothyroidism in an iodine-deficient toddler on soy milk and hypoallergenic diet

Soy-based infant formulas (SFs) are often consumed by cow's milk allergic children. However, some concerns have risen since soy intake may adversely affect thyroid function in iodine-deficient or subclinical hypothyroid individuals. We report the first Italian case of SF induced goiter and hypothyroidism registered in our country since National Iodine program has been instituted. Finally, we review cases previously reported in literature. A 22-month-old toddler with a previous diagnosis of cow's milk protein allergy came to clinical attention for important goiter and overt hypothyroidism. Detailed dietary anamnesis revealed that he was on a restrictive dietary regimen based on soymilk since 12 months of age. A temporary levothyroxine substitution was instituted to avoid hypothyroidism complications. Adequate iodine supplementation and diet diversification completely reversed SF-induced hypothyroidism and goiter, confirming the diagnostic suspicion of soymilk-induced thyroid dysfunction in a iodine-deficient toddler. This case report demonstrates the importance of careful dietary habits investigation and adequate micronutrients supplementation in children on a restrictive diet due to multiple food allergies in order to prevent nutritional deficits.

Compositional and Functional Considerations for Bovine-, Caprine- and Plant-Based Infant Formulas

Breastmilk is the optimal source of nutrition for infants. However, in circumstances where breastfeeding is not possible or feasible, infant formula provides an essential alternative to fulfil the nutritional requirements of the developing infant. Traditionally, the manufacture of infant formula has involved utilisation of bovine milk as a base ingredient, formulated with other nutrients and bioactive ingredients to closely match the composition of human breastmilk. While it is the most widely available type of formula on the market, bovine-based infant formula is not suitable for all infants, and therefore alternatives such as those based on caprine milk, soy and rice protein are becoming increasingly available. This review provides a detailed examination of the composition of infant formula prepared from bovine milk, caprine milk, soy, and rice protein sources. Available literature on nutrient bio-accessibility and aspects of protein functionality relevant to infant formula is discussed.

Perspective: A Legal and Nutritional Perspective on the Introduction of Quinoa-Based Infant and Follow-on Formula in the EU

Infants are vulnerable consumers and highly depend on dietary proteins for growth and development during their first months of life. Infant formula (IF) and follow-on formula (FOF) have been developed to meet these requirements, although few protein sources are currently allowed to be used. At the same time, allergies to these available protein sources are becoming more frequent. There is thus a need to explore alternative protein sources for infant nutrition. One alternative could be quinoa, which is a pseudocereal that is naturally free from gluten and has a high protein content and quality. This review assessed the composition, nutritional properties, and applicability of quinoa proteins for IF and FOF as well as the legal framework for their use in the European Union (EU). The protein quality of isolated quinoa proteins (IQPs) is relatively high compared with other plant-based proteins like rice. Besides, during the protein isolation process, unfavorable compounds are mostly removed, ensuring that the final product can comply with the maximum residue concentrations allowed. Overall, IF and FOF are strictly regulated under the Foods for Specific Groups (FSG) Regulation (EU) No 609/2013 and more research is needed before the introduction of IQP in such products is considered, but this review shows it has several promising features that warrant further investigation.

EAACI guideline: Preventing the development of food allergy in infants and young children (2020 update)

BACKGROUND

This guideline from the European Academy of Allergy and Clinical Immunology (EAACI) recommends approaches to prevent the development of immediate-onset / IgE-mediated food allergy in infants and young children. It is an update of a 2014 EAACI guideline.

METHODS

The guideline was developed using the AGREE II framework and the GRADE approach. An international Task Force with representatives from 11 countries and different disciplinary and clinical backgrounds systematically reviewed research and considered expert opinion. Recommendations were created by weighing up benefits and harms, considering the certainty of evidence and examining values, preferences and resource implications. The guideline was peer-reviewed by external experts, and feedback was incorporated from public consultation.

RESULTS

All of the recommendations about preventing food allergy relate to infants (up to 1 year) and young children (up to 5 years), regardless of risk of allergy. There was insufficient evidence about preventing food allergy in other age groups. The EAACI Task Force suggests avoiding the use of regular cow's milk formula as supplementary feed for breastfed infants in the first week of life. The EAACI Task Force suggests introducing well-cooked, but not raw egg or uncooked pasteurized, egg into the infant diet as part of complementary feeding. In populations where there is a high prevalence of peanut allergy, the EAACI Task Force suggests introducing peanuts in an age-appropriate form as part of complementary feeding. According to the studies, it appears that the most effective age to introduce egg and peanut is from four to 6 months of life. The EAACI Task Force suggests against the following for preventing food allergy: (i) avoiding dietary food allergens during pregnancy or breastfeeding; and (ii) using soy protein formula in the first 6 months of life as a means of preventing food allergy. There is no recommendation for or against the following: use of vitamin supplements, fish oil, prebiotics, probiotics or synbiotics in pregnancy, when breastfeeding or in infancy; altering the duration of exclusive breastfeeding; and hydrolysed infant formulas, regular cow's milk-based infant formula after a week of age or use of emollients.

CONCLUSIONS

Key changes from the 2014 guideline include suggesting (i) the introduction of peanut and well-cooked egg as part of complementary feeding (moderate certainty of evidence) and (ii) avoiding supplementation with regular cow's milk formula in the first week of life (low certainty of evidence). There remains uncertainty in how to prevent food allergy, and further well-powered, multinational research using robust diagnostic criteria is needed.

Growth Patterns of Indonesian Infants with Cow's Milk Allergy and Fed with Soy-Based Infant Formula

PURPOSE

The use of soy-based infant formula has increased widely in infants with cow's milk allergy (CMA). This study aimed to provide evidence on the growth pattern of CMA infants fed with soy-based infant formula in an Indonesian setting.

METHODS

A multi-site, intervention study was conducted among full-term and normal birth weight CMA infants. Within six months, the subjects were provided with a soy-based infant formula. Weight, height, and head circumference were measured at baseline, weeks 4, 8, 12, 16, 20, and 24. Adverse events were recorded by scoring atopic dermatitis and symptom-based clinical scores.

RESULTS

Based on the World Health Organization growth chart, we found that most of subjects had normal nutritional status for weight-for-age, length-for-age, weight-for-length, and head-circumference-for-age. There were statistically significant differences between baseline and end-line for weight-for-age, length-for-age, weight-for-length, and head circumference-for-age nutritional status. No allergic symptoms or intolerance toward soy formula were observed at the end of the intervention period.

CONCLUSION

These results show that infants fed with soy-based infant formula have a normal pattern of growth.

The role of soy plant-based formula supplemented with dietary fiber to support children's growth and development: An expert opinion

OBJECTIVES

Soy-based formula has evolved in usage and processing technology since its introduction in 1909, and has been used as substitute formula for infants or children with cow milk allergy since 1929. At present, personal opinions, religious background, availability, palatability, and cost are part of the reasons soy-based formula is chosen. Technology in processing soy-based formula has evolved from using soy flour to soy protein isolate, which provides advantages. However, concerns remain regarding the impact of its use on the growth and development of children.

METHODS

An expert meeting, attended by 12 experts, was initiated in Jakarta, Indonesia, to obtain an evidence-based consensus on the role of soy protein isolate formula, as well as its nutritional value to support growth and development.

RESULTS

Ensuring that plant-based formula (i.e., soy protein isolate formula) is fortified with key nutrients, such as calcium, iron, and dietary fiber is important.

CONCLUSIONS

Consensus was achieved, concluding that soy protein isolate formula is safe, affordable, and an alternative option for cow's milk-based formula for term infants.

Systemic reaction to an extensively hydrolyzed formula in an infant with cow's milk anaphylaxis

Background

Cow's milk allergy is the most common cause of food allergy in young children. Ingestion of milk products in children with a milk protein allergy can lead to anaphylaxis and must be avoided. Some guidelines suggest the use of an extensively hydrolyzed formula (EHF) in these cases; however, rare allergic reactions can still occur. Here, we presented a 3-month-old boy who developed anaphylaxis to a cow's milk formula. Subsequently, he developed a rare systemic reaction to soy and to an EHF.

Case

The patient had an unremarkable medical history and presented with signs and symptoms consistent with anaphylaxis after being fed cow's milk formula for the first time. Symptoms included immediate vomiting, wheezing, stridor, angioedema of eyelids and lips. Although intramuscular epinephrine was given, the patient continued to clinically deteriorate, becoming more lethargic and necessitating admission to the pediatric intensive care unit. Subsequently, a trial of soy formula ingestion reproduced the symptoms and an EHF was given. However, immediately after taking an EHF, he developed facial angioedema and diffuse urticarial lesions.

Conclusion

In most patients with a cow's milk allergy, an extensively based formula can be tolerated safely due to a hydrolyzed protein chain. However, medical providers must be vigilant when switching formula because a rare systemic allergic reaction to EHF can still occur.

Use of Soy-Based Formulas and Cow's Milk Allergy: Lights and Shadows

Soybean (Glycine max) is a species of legume native to East Asia and used in childhood diet for over 2,000 years in the East. Soy protein formulas have been available for almost a century. Nowadays, the increase in cow's milk allergy and vegetarian dietary preferences are driving consumers toward cow's milk alternatives. In this paper, we reviewed the nutritional composition of soy-based infant formula and discussed their possible use in pediatric age, mainly focusing on prevention and treatment of cow's milk allergy. Protein quality is determined by digestibility and amino acid content. Purified or concentrated vegetable proteins (e.g., soy protein and gluten) have high digestibility (>95%), similar to those of animal ones. For some intact vegetable products (e.g., whole cereals and pulses), protein digestibility is lower (80-90%). Food processing and heat treatment also influence protein digestibility. Considering these data, we tried to evaluate the possible use of soybean and derivatives in pediatric age, including the nutritional composition of soy formulas and the clinical indications for their use. Moreover, since plant-based beverages are being perceived as healthy by consumers and their use is growing on the market, we recommend that soy drink should not be used as a substitute for infant formulas or cow's milk in children younger than 24 months.

Dietary Soy Protein Isolate Attenuates Intestinal Immunoglobulin and Mucin Expression in Young Mice Compared with Casein

Dietary protein sources have profound effects on children and young animals, and are important for the gut barrier function and immune resilience. Milk and soy are the main sources of protein for children and young animals after weaning. The objective of this study was to compare the effects of dairy and soy proteins on the intestinal barrier in early development. Weanling C57BL/6 mice were fed AIN-93G diets prepared with casein or soy protein isolate (SPI) for 21 days. Compared with those fed with the casein diet, mice fed with the SPI diet did not change their body weight and organ coefficients, but increased their feed intake and ratio of feed to gain. SPI lowered the level of luminal secretory immunoglobulin A (SIgA) and downregulated the levels of IL-4, IL-13, polymeric immunoglobulin receptor (Pigr), Janus kinase 1 (Jak1), signal transducer and activator of transcription 6 (Stat6), and transforming growth factor-β (Tgfb) in the mouse ileum. Western blotting of ileal proteins confirmed that SPI suppressed the activation of the JAK1/STAT6 signaling pathway. Furthermore, SPI attenuated intestinal mucin production, as demonstrated by the decreased numbers of intestinal goblet cells and the reduced relative expression levels of mucin 1 (Muc1), mucin 2 (Muc2), trefoil factor 3 (Tff3), glucose-regulated protein 94 (Grp94), and anterior gradient homolog 2 (Agr2). The results indicated that the SPI diet could attenuate mouse intestinal immunity, as demonstrated by decreased SIgA and mucin production in the intestine. Therefore, we suggest that our findings should be of consideration when SPI or casein are used as dietary protein sources.

Technical opinion of the Asociación Mexicana de Gastroenterología on soy plant-based beverages

There has been a recent increase in the consumption of cow's milk substitutes, specifically plant-based beverages, which have erroneously been named "plant milks". Plant-based beverages do not have a standard of identity, and so their nutritional composition can vary from one brand to another, even within the same category. The aim of the present narrative review was to produce a technical opinion to serve as a frame of reference for sustaining the recommendation of soy plant-based beverages. Nutrition and gastroenterology experts that belong to the Asociación Mexicana de Gastroenterología jointly commented on and analyzed themes on plant-based beverages, and on soy drinks in particular, including their nutritional characteristics, consumption in children, and potential growth and development alterations, as well as soy drink consumption in adults and its association with gastrointestinal alterations and other conditions. Plant-based beverages, including those made from soy, are not a replacement for breastmilk or breastmilk substitutes. Soy beverages are considered safe and can enrich the varied diet of its consumers, as long as they are considered an additional liquid portion of the diet. They can be ingested by adults and children above two years of age that present with cow's milk protein allergy or lactose intolerance.

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper: Plant-based Milks

Parents and caretakers are increasingly feeding infants and young children plant-based "milk" (PBM) alternatives to cow milk (CM). The US Food and Drug Administration currently defines "milk" and related milk products by the product source and the inherent nutrients provided by bovine milk. Substitution of a milk that does not provide a similar nutritional profile to CM can be deleterious to a child's nutritional status, growth, and development. Milk's contribution to the protein intake of young children is especially important. For almond or rice milk, an 8 oz serving provides only about 2% or 8%, respectively, of the protein equivalent found in a serving of CM. Adverse effects from the misuse of certain plant-based beverages have been well-documented and include failure to gain weight, decreased stature, kwashiorkor, electrolyte disorders, kidney stones, and severe nutrient deficiencies including iron deficiency anemia, rickets, and scurvy. Such adverse nutritional outcomes are largely preventable. It is the position of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) Nutrition Committee, on behalf of the society, that only appropriate commercial infant formulas be used as alternatives to human milk in the first year of life. In young children beyond the first year of life requiring a dairy-free diet, commercial formula may be a preferable alternative to cow's milk, when such formula constitutes a substantial source of otherwise absent or reduced nutrients (eg, protein, calcium, vitamin D) in the child's restricted diet. Consumer education is required to clarify that PBMs do not represent an equivalent source of such nutrients. In this position paper, we provide specific recommendations for clinical care, labelling, and needed research relative to PBMs.

Veganism and paediatric food allergy: two increasingly prevalent dietary issues that are challenging when co-occurring

Vegan diets - defined as the exclusion of all foods of animal origin from the diet- are becoming popular. In recent years, the prevalence of food allergy has also increased, and disproportionately affects children. When vegan diets and food allergy co-occur, this combination can be challenging and pose risks of nutritional deficiencies, particularly during childhood. In this paper, we aim to summarise the major concerns regarding vegan diets and food allergy, review the literature on this topic, and provide some suggestions for healthcare providers, particularly dietitians and nutritionists, who work with food allergic, vegan patients and their family. When working with this patient population, a regular and complete medical nutrition history, including screening for any possible nutritional deficiencies, is warranted. Likewise, the routine tracking of serum markers (especially iodine, iron, zinc, calcium, Vitamins B12, D, B2, and A, selected n-3 fatty acids and protein, which are more abundant in animal vs. plant foods) and symptoms of co-morbid diseases, including asthma, is important, as comorbid diseases may increase energy and nutrient requirements. For infants and children, anthropometry ought to be tracked longitudinally at regular intervals to identify any deviations from the child's previous growth pattern, and to accommodate any increased requirements for growth and development. Correct diagnoses, education and allergy management must be disseminated to the family in a clear and appropriate manner. Children with allergy may have increased nutritional needs due to comorbidity. This is complicated by coincident food allergy and vegan diet as both impose diet restrictions (limiting sources of important nutrients, need for dietary variety and/or increased consumption due to reduced bioavaliability).

Vomiting Children: It's Not Always Gastroenteritis

Emesis is a common presentation in children. Many diagnostic considerations need to be made in a child with emesis and no diarrhea, particularly if lasting longer than 24 hours. The differential diagnosis includes trauma, increased intracranial pressure, obstruction, and metabolic abnormalities such as diabetic ketoacidosis. Prompt recognition with appropriate testing and management is needed. [Pediatr Ann. 2020;49(5):e233-e241.].

Standard and Specialized Infant Formulas in Europe: Making, Marketing, and Health Outcomes

Infant formulas are the only suitable substitute for human milk. The most common infant formulas are standard formulas based on cow's milk. In addition, there are formulas for infants showing signs and symptoms of intolerance and for clinical conditions such as allergy, prematurity, and gastrointestinal diseases. A comprehensive review of the literature was made to review the composition of standard and specialized infant formulas and analyze indications for use, real or presumed nutrition differences and properties, and impact on infant growth. A brief consideration on costs is outlined for each formula. Over the past few years, industrial production and advertising of infant formulas have increased. Human milk still remains the most complete source of nutrition for infants and should be continued according to the current recommendations. Few differences exist between infant formulas, both for the nutrition action and the macronutrient/micronutrient composition. Specialized infant formulas have limited indications for use and high costs. The role of the pediatrician is crucial in the management of infant nutrition, promotion of breastfeeding, and prescribing of specialized formulas only in specific clinical conditions.

Soy-Based Infant Formula: Are Phyto-Oestrogens Still in Doubt?

Although Scientific Societies have stated that there are very few indications for the use of soy-based formula (SF) in infant nutrition, their utilization rates have been repeatedly found to be higher than expected. It is likely that a significant role in this regard is played by the belief that the use of SF during infancy can reduce the risk of the development of several diseases later in life. Although no definitive data that can substantiate these claims have been collected, many people perceive soy consumption to confer significant health benefits and might also use soy for infant nutrition. However, not all the problems regarding safety of SF in infants have been definitively solved. Among risks, the potentially toxic role of the phyto-oestrogens contained in SF is not definitively established. In vitro and animal studies have raised suspicions that SF could have potentially negative effects on sexual development and reproductive function, neurobehavioral development, immune function, and thyroid function. Several studies in humans have aimed to assess whether the results of animal studies can be applied to humans and whether SF can be used in infants following the official recommendations. The results are somewhat conflicting. The aim of this narrative review is to discuss what is presently known regarding the impact of phyto-oestrogens in SF on early and late child development. PubMed was used to search for the studies published from January 1980 to June 2017 using the keywords: “soy,” “soy formula,” “child,” “phytoestrogens.” Analysis of the literature showed that a global evaluation of the impact of modern SFs on human development seems to suggest that their use is not associated with relevant abnormalities. Only children with congenital hypothyroidism need adequate monitoring of thyroid function.

Dietary modifications for infantile colic

BACKGROUND

Infantile colic is typically defined as full-force crying for at least three hours per day, on at least three days per week, for at least three weeks. This condition appears to be more frequent in the first six weeks of life (prevalence range of 17% to 25%), depending on the specific location reported and definitions used, and it usually resolves by three months of age. The aetiopathogenesis of infantile colic is unclear but most likely multifactorial. A number of psychological, behavioural and biological components (food hypersensitivity, allergy or both; gut microflora and dysmotility) are thought to contribute to its manifestation. The role of diet as a component in infantile colic remains controversial.

OBJECTIVES

To assess the effects of dietary modifications for reducing colic in infants less than four months of age.

SEARCH METHODS

In July 2018 we searched CENTRAL, MEDLINE, Embase , 17 other databases and 2 trials registers. We also searched Google, checked and handsearched references and contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs evaluating the effects of dietary modifications, alone or in combination, for colicky infants younger than four months of age versus another intervention or placebo. We used specific definitions for colic, age of onset and the methods for performing the intervention. We defined 'modified diet' as any diet altered to include or exclude certain components.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcome was duration of crying, and secondary outcomes were response to intervention, frequency of crying episodes, parental/family quality of life, infant sleep duration, parental satisfaction and adverse effects.

MAIN RESULTS

We included 15 RCTs involving 1121 infants (balanced numbers of boys and girls) aged 2 to 16 weeks. All studies were small and at high risk of bias across multiple design factors (e.g. selection, attrition). The studies covered a wide range of dietary interventions, and there was limited scope for meta-analysis. Using the GRADE approach, we assessed the quality of the evidence as very low.Low-allergen maternal diet versus a diet containing known potential allergens: one study (90 infants) found that 35/47 (74%) of infants responded to a low-allergen maternal diet, compared with 16/43 (37%) of infants on a diet containing known potential allergens.Low-allergen diet or soy milk formula versus dicyclomine hydrochloride: one study (120 infants) found that 10/15 (66.6%) breastfed babies responded to dicyclomine hydrochloride, compared with 24/45 (53.3%) formula-fed babies. There was little difference in response between breastfed babies whose mother changed their diet (10/16; 62.5%) and babies who received soy milk formula (29/44; 65.9%).Hydrolysed formula versus standard formula: two studies (64 infants) found no difference in duration of crying, reported as a dichotomous outcome: risk ratio 2.03, 95% confidence interval (CI) 0.81 to 5.10; very low-quality evidence. The author of one study confirmed there were no adverse effects. One study (43 infants) reported a greater reduction in crying time postintervention with hydrolysed formula (104 min/d, 95% CI 55 to 155) than with standard formula (3 min/d, 95% CI -63 to 67).Hydrolysed formula versus another hydrolysed formula: one study (22 infants) found that two types of hydrolysed formula were equally effective in resolving symptoms for babies who commenced with standard formula (Alimentum reduced crying to 2.21 h/d (standard deviation (SD) 0.40) and Nutramigen to 2.93 h/d (SD 0.70)).Hydrolysed formula or dairy- and soy-free maternal diet versus addition of parental education or counselling: one study (21 infants) found that crying time decreased to 2.03 h/d (SD 1.03) in the hydrolysed or dairy- and soy-free group compared with 1.08 h/d (SD 0.7) in the parent education or counselling group, nine days into the intervention.Partially hydrolysed, lower lactose, whey-based formulae containing oligosaccharide versus standard formula with simethicone: one study (267 infants) found that both groups experienced a decrease in colic episodes (secondary outcome) after seven days (partially hydrolysed formula: from 5.99 episodes (SD 1.84) to 2.47 episodes (SD 1.94); standard formula: from 5.41 episodes (SD 1.88) to 3.72 episodes (SD 1.98)). After two weeks the difference between the two groups was significant (partially hydrolysed: 1.76 episodes (SD 1.60); standard formula: 3.32 episodes (SD 2.06)). The study author confirmed there were no adverse effects.Lactase enzyme supplementation versus placebo: three studies (138 infants) assessed this comparison, but none reported data amenable to analysis for any outcome. There were no adverse effects in any of the studies.Extract of Foeniculum vulgare, Matricariae recutita, and Melissa officinalis versus placebo: one study (93 infants) found that average daily crying time was lower for infants given the extract (76.9 min/d (SD 23.5), than infants given placebo (169.9 min/d (SD 23.1), at the end of the one-week study. There were no adverse effects.Soy protein-based formula versus standard cows' milk protein-based formula: one study (19 infants) reported a mean crying time of 12.7 h/week (SD 16.4) in the soy formula group versus 17.3 h/week (SD 6.9) in the standard cows' milk group, and that 5/10 (50%) responded in the soy formula group versus 0/9 (0%) in the standard cows' milk group.Soy protein formula with polysaccharide versus standard soy protein formula: one study (27 infants) assessed this comparison but did not provide disaggregated data for the number of responders in each group after treatment.No study reported on our secondary outcomes of parental or family quality of life, infant sleep duration per 24 h, or parental satisfaction.

AUTHORS' CONCLUSIONS

Currently, evidence of the effectiveness of dietary modifications for the treatment of infantile colic is sparse and at significant risk of bias. The few available studies had small sample sizes, and most had serious limitations. There were insufficient studies, thus limiting the use of meta-analysis. Benefits reported for hydrolysed formulas were inconsistent.Based on available evidence, we are unable to recommend any intervention. Future studies of single interventions, using clinically significant outcome measures, and appropriate design and power are needed.

Effects of isoflavones on breast tissue and the thyroid hormone system in humans: a comprehensive safety evaluation

Isoflavones are secondary plant constituents of certain foods and feeds such as soy, linseeds, and red clover. Furthermore, isoflavone-containing preparations are marketed as food supplements and so-called dietary food for special medical purposes to alleviate health complaints of peri- and postmenopausal women. Based on the bioactivity of isoflavones, especially their hormonal properties, there is an ongoing discussion regarding their potential adverse effects on human health. This review evaluates and summarises the evidence from interventional and observational studies addressing potential unintended effects of isoflavones on the female breast in healthy women as well as in breast cancer patients and on the thyroid hormone system. In addition, evidence from animal and in vitro studies considered relevant in this context was taken into account along with their strengths and limitations. Key factors influencing the biological effects of isoflavones, e.g., bioavailability, plasma and tissue concentrations, metabolism, temporality (pre- vs. postmenopausal women), and duration of isoflavone exposure, were also addressed. Final conclusions on the safety of isoflavones are guided by the aim of precautionary consumer protection.

Infant colic: mechanisms and management

Infant colic is a commonly reported phenomenon of excessive crying in infancy with an enigmatic and distressing character. Despite its frequent occurrence, little agreement has been reached on the definition, pathogenesis or the optimal management strategy for infant colic. This Review aims to delineate the definitional entanglement with the Rome IV criteria, which were published in 2016, as the leading, most recent diagnostic criteria. Moreover, neurogenic, gastrointestinal, microbial and psychosocial factors that might contribute to the pathophysiology of infant colic are explored. This Review underlines that a comprehensive medical history and physical examination in the absence of alarm symptoms serve as guidance for the clinician to a positive diagnosis. It also highlights that an important aspect of the management of infant colic is parental education and reassurance. Management strategies, including behavioural, dietary, pharmacological and alternative interventions, are also discussed. Owing to a lack of large, high-quality randomized controlled trials, none of these therapies are strongly recommended. Finally, the behavioural and somatic sequelae of infant colic into childhood are summarized.

Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition

This document serves as an update of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 2009 clinical guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD) in infants and children and is intended to be applied in daily practice and as a basis for clinical trials. Eight clinical questions addressing diagnostic, therapeutic and prognostic topics were formulated. A systematic literature search was performed from October 1, 2008 (if the question was addressed by 2009 guidelines) or from inception to June 1, 2015 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Clinical Trials. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to define and prioritize outcomes. For therapeutic questions, the quality of evidence was also assessed using GRADE. Grading the quality of evidence for other questions was performed according to the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) and Quality in Prognostic Studies (QUIPS) tools. During a 3-day consensus meeting, all recommendations were discussed and finalized. In cases where no randomized controlled trials (RCT; therapeutic questions) or diagnostic accuracy studies were available to support the recommendations, expert opinion was used. The group members voted on each recommendation, using the nominal voting technique. With this approach, recommendations regarding evaluation and management of infants and children with GERD to standardize and improve quality of care were formulated. Additionally, 2 algorithms were developed, 1 for infants <12 months of age and the other for older infants and children.

Preventive effects of royal jelly against anaphylactic response in a murine model of cow's milk allergy

CONTEXT

Royal jelly (RJ) has long been used to promote human health.

OBJECTIVE

The current study investigated the preventive effects of RJ against the development of a systemic and intestinal immune response in mice allergic to cow's milk proteins.

MATERIALS AND METHODS

Balb/c mice treated orally for seven days with RJ at doses of 0.5, 1 and 1.5 g/kg were sensitized intraperitoneally with β-lactoglobulin (β-Lg). Serum IgG and IgE anti-β-Lg were determined by an enzyme-linked immunosorbent assay (ELISA). Plasma histamine levels, symptom scores and body temperature were determined after in vivo challenge to β-Lg. Jejunums were used for assessment of local anaphylactic responses by an ex vivo study in Ussing chambers and morphologic changes by histological analysis.

RESULTS

RJ significantly decreased serum IgG (31.15-43.78%) and IgE (64.28-66.6%) anti-β-Lg and effectively reduced plasma histamine level (66.62-67.36%) (p < 0.001) at all the doses tested. Additionally, no clinical symptoms or body temperature drops were observed in RJ-pretreated mice. Interestingly, RJ significantly reduced (p < 0.001) intestinal dysfunction by abolishing the secretory response (70.73-72.23%) induced by sensitization and prevented length aberrations of jejunal villi by 44.32-59.01% (p < 0.001).

DISCUSSION AND CONCLUSIONS

We speculate that using RJ may help prevent systemic and anaphylactic response in allergic mice. These effects may be related to its inhibitory effects on the degranulation of mast cells.

Comparative study of the quality characteristics of defatted soy flour treated by supercritical carbon dioxide and organic solvent

Defatted soy flour is a potential source of food protein, amino acids, ash and isoflavones. The supercritical carbon dioxide (SC-CO₂) and a traditional organic solvent extraction methods were used to remove fat from soy flour, and the quality characteristics of a control soy flour (CSF), defatted soy flour by SC-CO₂ (DSFSC-CO₂) and defatted soy flour by an organic solvent (DSF-OS) were compared. The SC-CO₂ process was carried out at a constant temperature of 45 °C, and a pressure of 40 MPa for 3 h with a CO₂ flow rate of 30 g/min. The DSFSC-CO₂ had significantly higher protein, ash, and amino acids content than CSF and DSF-OS. The sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) analysis demonstrated that CSF and DSFSC-CO₂ had protein bands of similar intensity and area that indicated no denaturation of protein, whereas DSF-OS showed diffuse bands or no bands due to protein denaturation. In addition to higher nutritional value and protein contents, DSFSC-CO₂ showed superior functional properties in terms of total soluble solids content, water and oil absorption, emulsifying and foaming capacity. The SC-CO₂ method offers a nutritionally and environmentally friendly alternative extraction processing approach for the removal of oil from high-protein food sources. It has a great potential for producing high-protein fat-free, and low-calorie content diet than the traditional organic solvent extraction method.

Exploring hypotheses and rationale for causes of infantile colic

BACKGROUND

Infantile colic is a frequent problem in neonates and infants. This review addresses current management including the results for nutrient modifications; soy-based formulas; and prebiotics, probiotics, and synbiotics.

PURPOSE

Given the evidence that there is still an unmet clinical need, as current treatments are incompletely efficacious, we have examined the evidence around three hypothetical mechanisms that could potentially be involved in etiopathogenesis of infantile colic: immaturity of bile acid mechanisms that alter intraluminal and absorptive mechanisms, immaturity in motility and alterations in the microbiome. Understanding these potential mechanisms may lead to the introduction of diagnostic procedures that should enhance the selection or individualization of therapy for infantile colic.